Archive for April, 2009

Eye surgeon robbed blind by scammer

By Mike Broad - 28th April 2009 3:54 pm

Hello friend! Greetings from Nigeria! I’m a terribly wealthy prince who has fallen on hard times. My vast riches are tied up in an account in the Cayman Islands. All I need to liberate them is £10k. Could I borrow this from you? I would pay you back ten times the amount…

And so starts a very predictable scam. Just about everyone has now received a communication like this. And just about everyone has immediately binned it…except the odd eye surgeon.

It has to be said that this is sad rather than funny, which makes this a very poor start to a supposedly hilarious new blog (mental note to self: must write funnier stuff).

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Lessons from Jade Goody’s public battle with cancer

Dr Sarah Burnett-Moore, consultant radiologist, London - 27th April 2009 11:17 am

Watching Jade Goody live out her terminal weeks in the press brought back painful memories for me. I had breast cancer in 2005. The way that she was viewed at one point with soft focus, the next with flash bulb severity, mimics the emotional roller coaster that cancer treatment provokes. 

The highs and lows remain with you into survivorship, worsened at every follow up appointment. Two years ago, after being accused of bullying on Celebrity Big Brother, she was the nation’s hate symbol. One radio contributor even suggested she deserved cancer because of her racist comments. A death sentence for an inappropriately judged gaffe. But, as death approached, she was commended for her bravery by the Prime Minister.

I think she was remarkably brave in dealing with the media over her diagnosis and treatment. Unlike some celebrities, who have chosen to hide the physical side of their treatment, even on her wedding day, at a time when most women spend hours having their hair tortured into elaborate bird’s nests, she wore her bald head with pride.

Particularly poignant, was her admission to the hospice because of the hallucinations that she suffered. When you start chemotherapy, the oncology team is keen to make sure that you understand the side effects of chemotherapy, and the potential treatments to alleviate them. They will tell you about hair loss, lethargy, nausea, weight gain, skin thinning, and a seemingly endless list of physical manifestations.

No one dares warn you about the almost inevitable depression, possible paranoia and delusional states that can develop. The press blamed Jade’s pain relief, but I can tell you, from personal experience, that combinations of chemotherapeutic agents, and high doses of steroid, can produce similar symptoms.

When you are having chemo, you see the team on a regular basis. Every cycle your bloods, weight, blood pressure, and in-dwelling line are meticulously checked. But no one even takes five minutes to check on your mental wellbeing.

This strikes me as the biggest omission in cancer care. At least I did not have to have my distress displayed to the nation. On all counts, Jade was not so lucky.

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High earners affected by pension changes

By Justine Roberts - 23rd April 2009 1:33 pm

The recent budget and its impact on pensions is a good place to start for the Money Matters blog. Many consultants will be affected by the changes to tax relief on pension contributions made on or after 6 April 2011. Although the Chancellor, Alistair Darling, hasn’t got rid of higher rate tax relief on pensions completely, he has made far reaching and sweeping changes which will affect consultants earning over £150,000. 

It is intended to restrict tax relief for those earning over £150,000, with a gradual tapering down of relief, so that anyone earning over £180,000 will only receive basic rate tax relief on contributions. There will be no advantage in increasing investment between now and 2011 as these new rules would apply immediately for those whose income now, or in the previous two tax years, was more than £150,000 and who make any changes from their normal pattern of contributions or the normal way they accrue benefits. This is designed to remove any advantage of increasing pension contributions prior to 6 April 2011.

More investigation is needed to establish the full impact of the small print, especially with regard to how this will affect NHS pension contributions and added years. There is no doubt that these sweeping new measures will affect a lot of consultants and their pension planning from 2011 onwards.

For those earning less than the thresholds above there will still be the ability to claim 40% tax relief on pension contributions, so now is the time to consider boosting contributions before higher rate tax relief gets removed completely. Pension planning has always been a tax advantageous way of saving for retirement, as 25% of the fund can be taken free of tax prior to the residual fund being used to fund an income in retirement. A quick example can show how tax effective pensions are. Tax relief on contributions at 40% and the ability to claim back 25% of the fund tax free at retirement makes pensions a must for higher rate tax payers. A fund of £100,000 will effectively only cost the investor £35,000. This is only looking at the contributions made and not considering any growth in the fund.

Investing in pensions does not necessarily mean taking risk with the funds. Investing into a cash fund is low risk, whilst still taking advantage of the tax allowances for higher rate tax payers, whilst they are still available. The additional pension scheme through the NHS, which replaced added years last year, is also a low risk option, whilet still benefitting from tax advantages.

We will cover the pros and cons of different pension planning routes in future blogs and provide updates on the changes announced in the budget as soon as we can.

● Justine Roberts is a director of Medical and Financial, which provides independent financial consultancy to doctors. Contact her at Justine@medicalandfinancial.com, or visit www.medicalandfinancial.com for more information.

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Juniors lack confidence in MMC

By Mike Broad - 21st April 2009 11:57 am

Doctors continue to have little confidence in standards of training and care delivered under Modernising Medical Careers (MMC), a survey by Remedy UK reveals. 

Despite a year passing since the Tooke Report, and two from the MTAS debacle, the overwhelming majority of doctors remain opposed to MMC. Seventy eight percent of 877 doctors claim patient care and postgraduate training is worse now than before MMC. 

“I can’t see a single benefit,” one respondent lamented. “Honestly, I can’t. MMC has managed to achieve the exact opposite of everything it was intended to achieve – poor training, reduced flexibility, a lost tribe of SHOs and a disenchanted workforce.”

Fifteen percent did acknowledge that MMC has positive aspects but with the caveat that implementation was poor. Another respondent summed up many of the comments when they described MMC as: “Good in theory, very bad in practice.”

MMC is clearly having an ongoing impact on doctors’ morale. Just under a quarter of respondents expressed a desire to leave medicine and do a different job, while just over a quarter would not advise someone to take up a career in medicine.

“The job is neither stable nor well paid considering the number of hours worked,” complained another respondent. “Trusts work the system to ensure trainees receive minimum banding. Training is continually restructured in a way which is ill thought out and geared towards saving money. The role of the doctor is displaced by non-medical specialists with narrow and limited responsibility. And the consultant grade, which I have been aiming for, will be radically different by the end of my training and I will undertake it with a fraction of the experience of my predecessors.”

One doctor simply said: “Become a dentist or a lawyer instead.”

While many doctors were negative about MMC, there was a much more positive reaction to being a doctor. It’s still considered a good job, despite the changes. Of the sample, 52% are satisfied in their work against 29% who are dissatisfied. Many will also still recommend it as a career. One respondent commented: “Go for it! Things will get better and it’s got to be better than the City right now…”

But there is a price to pay for becoming a doctor. The survey shows that the average debt on graduation of these respondents was nearly £15,000. Nearly half were still paying off student loads.

There’s no doubt that many doctors remain angry with those responsible for MMC. Sixty four percent of respondents claim MMC has had a detrimental effect on their careers.

One described it as: “A disgraceful and catastrophic episode imposed by deceitful quislings who lied about their real intentions and who betrayed their colleagues and the profession.”

Another said: “It’s positive that I got the job I wanted. But it was a shattering and degrading experience. I’m now very cynical about senior doctors and politicians, and especially senior doctors who are also politicians.”

The Department of Health said sufficient efforts are already made to canvass doctors’ opinions. “The deaneries, colleges and the MMC programme have a range of ways of listening to and taking account of the views of doctors as part of annual planning for recruitment and postgraduate medical education,” said a spokesperson. “The current recruitment process and structure of training is based on feedback from consultation, an online survey of junior doctors and a programme of major discussion events with doctors across the regions that took place last year.”

Lindsay Cooke, co-chair of Remedy UK, wasn’t surprised by the ongoing resentment.

She said: “MMC is a political construct which offends almost every core value today’s doctors possess. It was untried and untested; it compromises individual autonomy and choice; it breaks the apprentice model of experiential learning; and it turns doctors from team member to shift worker.

“Doctors are special people, for sure, but they’re people first. MMC turns them into widgets or cogs in a medicine delivery machine.”

She believes the government needs to conduct a comprehensive survey into doctors’ opinion of MMC.

Remedy is also calling for full implementation of the Tooke Report. A DH spokesperson said: “Many of the changes were in the NHS Next Stage Review and are being taken forward.”

Cooke wants NHS: Medical Education England (MEE) – a new independent body advising the government on education, training and workforce policy – to be strengthened, “with teeth and led by those experienced in medical training would be a good start”.

“Advisory committees such as MEE have significant power and influence,” responded the DH spokesperson. “For example, Ministers have accepted every recommendation made by the MMC England Programme Board. In this way, advisory bodies can directly influence policy decisions. The authority and influence of MEE comes from the quality and clarity of advice that it provides to Ministers.”

Remedy UK Survey

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Review of prescription charges

By Mike Broad - 11:08 am

In April, prescription charges for cancer patients in England were abolished.

While oncologists are relieved that the government has removed a significant deterrent to their patients accessing appropriate medicines, others want further reform of the charging system. All other conditions subject to prescription charges remain unchanged, despite evidence suggesting the system is both iniquitous and detrimental to patients’ health.

Many ask why cancer should be exempted when asthma, multiple sclerosis and mental health problems aren’t? These also involve the kinds of people who cannot afford the medicines they need – with the prescription charge increasing to £7.20 for 2009/2010 – which can lead to further problems with unplanned hospital admissions.

Back in 2001, research by the Citizens Advice Bureaux showed that 28% of those who had paid charges failed to get all or part of the prescription dispensed because of the cost. This was estimated to be about 750,000 people, with single parent households and those with long term conditions being worst affected.

Then in 2006, Royal Pharmaceutical Society of Great Britain research suggested that patients couldn’t understand the rationale on exemption and felt the charge was too high, particularly for those taking multiple medications.

Wales introduced free prescriptions in April 2007, and Scotland and Northern Ireland are currently reducing charges prior to free prescriptions in April 2011 and April 2010 respectively.

In England, the government has set up a review of prescription charges – led by Professor Ian Gilmore, president of the Royal College of Physicians – to consider which long-term conditions should be exempted. But, it is not the fundamental review of the purpose and value of prescription charges that many would like to see.

The BMA is calling on the Department of Health to abolish prescription charges in England altogether.

It claims that the current exemption categories are often illogical and unfair, and extending these categories to include long-term conditions will add to the inequities in the system and create new ‘winners’ and ‘losers’.

Legislation providing for prescription charges was not passed until the Labour Government’s NHS (Amendment) Act 1949. This enabled such a charge, and exemptions to it, to be introduced by regulations. Although the power was introduced in 1949, the charge itself was not introduced until 1952, under a Conservative Government. Apart from a period between 1965 and 1968, a prescription charge has continued in England ever since.

The current list of exemptions has been unchanged since then and does not reflect changes in medical treatment.

The BMA highlights exemption inconsistencies. Patients on thyroxine replacement therapy for an under active thyroid are exempt from charges, despite it being a cheap drug, while those with asthma and heart disease, who may require multiple medication for a prolonged period, are not. Similarly cystic fibrosis, which requires people to take a large number of drugs throughout their life, is not exempted because 40 years ago patients didn’t survive beyond childhood.

Defining a modern, definitive list of exempted chronic diseases is not easy, and is complicated by increasing polypharmacy and comorbidity.

But then scrapping prescription charges is not yet considered an affordable policy option for the NHS. While only 11% of prescriptions attracted a charge (and this will have lowered with cancer’s exemption), this still generates £450m per year in revenue. Cancer’s exemption will reduce this by about £16m a year.

Jonathan Fielden, chair of the BMA’s CCSC, said: “In NHS terms the revenue from prescription charges is a relatively small sum and comes with immense bureaucracy,” he said.

“It means some individuals are parting with considerable amounts of money to treat their conditions while others, with similar health burdens, are not. It would be more equitable if charging were done away with altogether. Instead of spending money on PFIs or the private sector, we should invest in scrapping prescription charges.”

The Government is clearly opting to take the middle ground agreeing that access to certain medicines needs to be improved, calling for a fairer system of prescription charging in England and setting up a review limited to long term conditions.

If, of course, its findings prove insubstantial or inconsistent when it reports to the health secretary this summer then pressure will continue to mount for a full review of the prescription charging system.

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Blowing the whistle on bullying trusts

By Stephen Campion, chief executive of HCSA - 20th April 2009 2:02 pm

I returned from holiday in South Africa only to find on my first day back in the office that my recharged battery drained very quickly. First day back is always a shock but this time it included an invitation to talk on Radio 5 Live with the Patients Association between 11 pm and midnight.

Radio 5 Live was not the only media wanting to talk about the events in Staffordshire. How could a trust that had gained foundation status in February 2006 be subject to a full blown Healthcare Commission investigation the very next month? How could such appalling standards of care not only have taken place but why were they not picked up? Is this an indictment of government targets? And so the questions and debate went on, and on, and on!

The trouble is that the issues are not particularly unique, although the scale of the problems might have taken some by surprise. And then only a few days later the Healthcare Commission publishes yet another critical report, this time about Birmingham’s specialist children services. More press to deal with.

Welcome back to the real world and the NHS, I thought. And full marks to those doctors who did their duty to their patients and the profession by putting their concerns above self-preservation. It is difficult to defend the indefensible; £60k paid by a government minister to fund a ‘second home’ owned by his parents or a meagre few quid taken by a cabinet minister from the public purse to fund a dodgy film on digital TV.

But what about the injustices within the NHS? Surely, the caring profession should be managed by those who care for their patients and staff. My experience is that there are some trust managements that do; but there are too many examples of management by fear and victimisation.

I gather blogs are meant to be provocative and make no apology for raising the intimidatory culture of some trusts as an issue. Am I alone in being worried by this? I don’t think so given the number of my members who ask for HCSA advice everyday, and personally seeing what can and does happen on the shop floor. What really worries me are those who want to highlight their concerns but are afraid to do so, or are not even protected by membership of a trade union.

Where I come across poor quality standards of patient care and intimidatory management I defend my members to the hilt. Is the challenge of dealing with this culture of fear and intimidation on your agenda too? I hope so; doctors must stand up and be counted but only with the benefit of good and professional advice. The challenge for me is to advise members how to deal with this issue, and to encourage membership of a trade union to such an extent that I do not just need, but deserve, a holiday!

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No easy solutions to WTD so why implement now?

By Mr Matt Jameson Evans, co-chair of Remedy - 19th April 2009 2:27 pm

A bewildered profession is bearing witness to frenzied debate, speculation and disagreement over the implementation of a 48-hour week for juniors on 1 August.

As the seconds tick away towards the deadline, a simple question is left hanging in the air: “Why now?”

Leaving aside the questionable timing, the debate boils down to two fundamental questions:
• Can we be sure that all affected services can cope with a 14% reduction in working time?
• Is the cost of a more palatable trainee lifestyle a consultant body with significantly less experience in the future?

The consequences of a chronically understaffed, stretched service are fresh in the public consciousness; look no further than the recent reports on the Mid-Staffordshire NHS Foundation Trust and the Birmingham Children’s Hospital.

It’s is arguably a brave stance for the Secretary of State Alan Johnson to dig in his heels on the EWTD in light of these events. You hope that the alarm raised by key members of the profession about service shortages in August is ringing around in his head right now.

But the question of training always attracts less media attention. With a cause and effect lead-time of 10 to 15 years the reasons are obvious. It was therefore good to see training raised as a central issue in the March debate on EWTD in Parliament by the shadow health minister.

Not so encouraging was the response from the Secretary of State for Health as to why trainees no longer need exposure to patients. “Developments in new technology such as virtual reality surgical simulators mean that there is increasingly, and thankfully, less need for inexperienced trainee surgeons to practice their skills directly on patients,” he declared.

This cynical abuse of logic was trawled out during the roll out of MMC as the fundamental reason why the progressive reduction of surgical training from 30,000 hours to 6,500 wasn’t going to have an impact on patient care.

It bubbled up from a few scattered developments in training technology (which have almost zero impact on the broad base of current trainees) and was inflated into a concrete fact to prop up policy decisions in the Department of Health.

It should be resisted as an idea at all costs, unless you know more about the advance of technology than I do and have already pre-paid for your ticket to the moon and can guarantee that you won’t be requiring surgery in the UK in 20 years time.

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Why postpone the inevitable WTD

Mr Paul Thorpe, consultant spinal surgeon, Taunton - 10:48 am

I can’t believe those filthy Europeans are trying to limit our working hours again. No wonder my esteemed colleagues at the Royal College of Surgeons, British Orthopaedic Association and Association of Surgeons in Training are getting hot under the collar.

Interestingly, juniors in this country were firmly in favour of a 48-hour week at that time and, more interestingly, that was not specialty specific i.e. the surgeons wanted to lay about as much as everyone else.

They’ve barely had 13 years to get used to the idea. It was just yesterday, in 1996, that the BMA’s Junior Doctors Committee (JDC) started warning the Department of Health (DoH) and Royal Colleges about the implications of the European Working Time Directive for doctors in training.

As usual, one half called the JDC shroud wavers, the other thought we had designed the legislation so that ‘layabout’ GPs and psychiatrists could have an easy life. I spent a large portion of my time in the BMA shuttling to Brussels to try and mitigate the impacts of the EWTD, and surveying what juniors actually thought about it (at least what they thought about it when their boss wasn’t listening).

Unfortunately, the DoH and royal colleges didn’t grasp the nettle of changing how we work and train until EWTD was upon them. Now that it is getting tough, and juniors and hospitals alike are feeling the pinch, what is their answer? Let’s see if we can opt out.

I have a prediction for them. The Government will say that we have to implement it and the EU will agree. Trying to close your eyes and hope it goes away may have worked for monsters under the bed – but this monster is under your quilt with you already, and is licking your thigh getting ready for a big bite.

Why don’t we use this opportunity to really change the way we do training in the UK? The JDC had a plan then, I have a plan now (happy to discuss with anyone interested enough to listen), or we can keep walking out on the beach wondering where the sea has gone, with the inevitable result when the law of geophysics reasserts itself.

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